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Home My WebLink About0344 ANNABLE POINT ROAD - Health 344 Annable Point Road, Centerville LA 192 i i E UPC 12534 No.2_OR � HASTINGS,MN 00 Commonwealth of Massachusetts -W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Cr) Hillard Welch Owner Owner's Name information is ✓ Ma 02632 6/15/17 � required for every Centerville - page. City/Town State Zip:Code bate of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important:When A. General Information s/ /a39a-- filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth MA . 02664 City/Town State - Zip Code 508-364-9587 S113522 Telephone Number License Number B..Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b c pproving Authority c, Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal Systerm.Form - Not for Voluntary Assessments t 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. - Comments: System contains a 1500 GI septic tank as well as a concrete distribution box and 5 H2O flo diffusers B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check.the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if.it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N . ❑ ND (Explain below): t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 c f Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code` Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):. ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to.broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ 'N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection for m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) . determines that the system is functioning in a manner that protects the public health, safety and environment: ❑. The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3113 Title 5 Official Inspection porm:Subsurface Sewage Disposal System•Page 4 of 17 , 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage.Disposal System.Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is Centerville Ma 02632 6/15/17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.,[This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition'to the questions in Section D.. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 y t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form - Not for Voluntary,Assessments F 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? r ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper.maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. .0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 6 of 17 L Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name . information is required for every Centerville Ma 02632 6/15/17 page.. City[Town State Zip Code Date of Inspection D. System Information Description: � Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal us ?e ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 254 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the'Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for,every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe.below): General Information Pumping Records: Source of information: every 2 years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 t L f f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all-components, date installed (if known) and source of information: 23 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 6 Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet , Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: . Sludge depth: 6 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 commonwealth of Massachusetts y W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments' M • 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is Centerville required for every Ma 02632 6/15/17 page. Clty[Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3"� - Distance from top of scum to top of outlet tee or baffle 4211 Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No eveidance of leaking Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments k .344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd. Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert H2O. Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc:): Pump Chamber(locate on site plan): Pumps in working order. El Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump.chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 6 ' ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M , 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 .page. City/Town State Zip Code Date of Inspection . D. System 6nformati®n (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition ( cond t on of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding no breakout Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts _. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Fora, _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . t Cornmonweafth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 18ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan. 5ft seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 /;3^ 7l 6 1 6 0 t 5 T �1 OWN OF BARNSTABLE LOCATION J�qll SEWAGE # �S�"f 7�� VILLAGE [i�h `fit%/�f� ASSESSOR'S MAP &LOT �0 i' INSTALLER'S NAME&PHONE NO, SEPTIC TANK CAPACITY LEACHING FAC.II.PIY: (ty (size) �/4�'r// NO.OF BEDROOMS. j BUILDER OR OWNER PERMITDATE: C� ��I"� `-" COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ` Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) J S 62 Feet Edge of Wetland and Leaching Facility(If any wetlands'exist 1 ' within 300 feet of leaching facility) _ / 1 �% Feet Furnished by > r 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 344 Annable Point rd Property Address Hillard Welch Owner Owner's Name information is required for every Centerville Ma 02632 6/15/17 page. City(Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater' ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tons-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory srncs�lj. Report Prepared For: Report Dated: 3/16/2007 Hillard W. Welch Order No.: G0739765 344 Annable Point Road Centerville, MA 02632 Laboratory ID#: 0739765-01 D . Description: Water-_(Drinking Water Sample#: Sampling Location 344 A�nn point Rd:Centerville;MA—j —y' Collected: 3/13/2007 Collected by: H.Welch Map 212 Parce1007 Received: 3/13/2007 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 3/13/2007 Copper ND mg/L 0.10 1-3 SM 3111B Iron 3/15/2007 ND mg/L 0.10 0.3 SM 3111B 3/15/2007 Sodium 9.3 mg/L 1.0 20 SM3111B 3/15/2007 Total Coliform Absent P/A 0 0 SM9223 3/13/2007 Conductance 76 umohs/cm 2.0 EPA 120.1 3/13/2007 pH 5.7 pH-units 0 EPA 150.1 3/13/2007 Wat ser ani le meets the recommended limns for rlrinkin�water of all the above tested arameters.� Pf c p Approved By: ( hector) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 JY. CERTIFICATE OF ANALYSIS Page: 1 s Barnstable County Health Laboratory s. Report Dated: 9/29/2006 Report Prepared For: Order No.: G0638301 Hillard W. Welch 344 Annable Point Road Centerville, MA 02632 Laboratory In#: 0638301-01 Description: Water-Drinking Water Sample#: Sampling Location 344 Annable Point Rd.Centerville,MA Collected: 9/25/2006 Collected by: H.Welch Map 212 Parcel 7 Received: 9/25/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.10 to EPA 300.0 9/25/2006 LAB: Metals Copper BRL mg/L 0.10 1.3 SM 3111B 9/29/2006 Iron BRL mg/L 0.10 0.3 SM 311113 9/29/2006 Sodium 9.0 mg/L 1.0 20 SM 3111B 9/29/2006 LAB: Microbiology Total Coliform Absent P/A 0 0 SM9223 9/25/2006 LAB: Physical Chemistry Conductance 180 umohs/cm 2.0 EPA 120.1 9/25/2006 pH 7.7 pH-units 0 EPA 150.1 9/25/2006 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: � ab e'§ 3 . CZn ,1 r a � -, p• r _ 1 RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 `-- -�No. 1.7see THE COMMONWEALTH OF MASSACHUSETTS �^ S/ PUBLIC H ALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for DigosmY *potem C ow9truction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location lA�¢dw o L ` � OwneNam e,e,.A �reess and Te.No. r7 4-4_ _617 WA- t ;71 c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5=49—3r-2- _ L�WW a9y''Er Lsi✓9> /,06 4 �f�ljlN��i�o.�D— /L/•� �7�6 J� Type of Building: Dwelling No.of Bedrooms_ Garbage Grinder(�) Other Type of Building iQlA 4 No.of Persons z Showers( ) Cafeteria( ) Other Fixtures Design Flow 4-r gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil4�zg 4!� ze Nature of Repairs or Alterations(Answer when applicable) • 7pL--i� X . _W Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E iron ntal ode and not to place the system in operation until a Certifi- cate of Compliance has been issued b his of e �� Signed Date llfk5 Application Approved by Application Disapproved for the f owing reasons Permit No.7 5: — 17 it Date Issued ;r "'-'5 �.✓/��/ !�"/" THE COMMONWEALTH OF MASSACHUSETTS 1 t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES-MASSACHUSETTS t - 2ppricatiou for Migaal 6peum Cow5truction Permit Application is hereby made for a Permit to Construct( -)or Repair( )an On-site Sewage Disposal System at: y Location Address or Lot No. r n" r Ownel I Name,Address and Te).No. O �,^T= -6 / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S og_ W 2 54S^ Type of Building;` ' Dwelling--No.,of Bedrooms_ Garbage Grinder(/�) Other Type of Building�ls 46 No. of Persons 2 Showers( ) Cafeteria( ) f Other Fixtures I IC - Design Flow 4-,-z /P /Z,9'✓ gallons per day. Calculated daily flow gallons. r Plan Date Number of sheets Revision Date �. Title'`=,,:A. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4 \ Date lastfiinspected: h4. :Agreement: \ s _P fie undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in acc4d ce with the provisions of Title 5 of the E viron nta ode and not to place the system in operation until a Certifi- - `cote of Compliance has been issued b his of e / t- „Signed "c /0� 01 Date 4A A,pplication Approved by ' Application Disapproved for the Mowing reasons . M Permit No./ - 1 ( Date Issued ------=—=------------------—=---T� _---------- --___ =_----- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO C RTIFY,that the Onn--site Sewage Dis`�o$al System installed( )or repaired/replaced(/on by / /'�JF��O / G.;k� ,P`/!/G X_ for ,£ --as i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated V B -9' j Use of this system is conditioned on compliance with the provisions set forth below: ' CT�No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=ig;pogar *p5ttewm Con!6truction Permit Permission is herby granted to d f �T� ��✓��f�C �� to construct(V )repair( )an On-site Sewage System located at it/�✓4 Ell i. o and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: J of Approved by it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE ON FORM l Address of property 3y41 �^�N�d�. E ✓" i^� C. oac�Q UE'JV (/�l�,DZG3 Owner's name Gl/E-4-A.. ,-/ 5��7 Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. VorNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period . Large volumes of water have not been introduced into the system recently or- as part of this inspection. ,.w .4.As built plans have been obtained and examined. Note if they are not available with N/A. ✓"he facility or dwelli:.= was inspected for signs of sewage back-up. The site was inspected for signs of breakout. jV 4-1 All system components, �Wcluding the SAS, have been located on the Lite. ��. The septic tank manholes were uncovered, opened,. and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge , depth of scum. voe1he size and location of the SAS on the site has been determined based on existing information cr approximated by non-intrusive methods. VOO'The facility owner (and occupants, if. different from owner) were prov: :;ed with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or. no jQ_ laundry connected to system, yes- or no -YJ�S seasonal use, yes or no If nonresidential, calculated flow: Water fneter readings, if available: /�- ✓�'�'TE v" � Last date of occupancy GENERAL INFORMATION Pumping records and source of information: S System- pumped as part of inspection, yes or no if yes , volume pumped 900 Reason for pumping: 'To 0401 ut % H14 /t aev�•�cicua�.-cti was 09 Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool of, /vccr�o--sj Privy Shared system- (yes or no) .(if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: �DSKct�t.4 /V� Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOk= PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation, not required, but may be approximated by non-intrusive. methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number G ia, Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) jWO CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation., recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, - level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' D� 1,300, / t�,0�/iyvrGt 3� DEPTH TO GROUNDWATER i °-� (Ie4- depth to groundwater method of determin tion or a pproximation: Tit&Z& L4 a z e Z&& e i.5 3 H' trX 6 /+ Q u A A Am a c t o 3y V' tJ.t kv C Q A.)O -91� �A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? . Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of .the SAS, cesspool or privy: .- 424W.;Aj b . Cd/l�-n-/1 AE UE.-�e— below the high groundwater elevation? �Sftv� && 70—s 7✓& - Z_� CAe-f.0 FVR. A t AS IC7-- within 50 feet of a surface water? he within . 100 feet of a surface water supply or tributary to a surface water supply? within a Zone, I of a public well? 'within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis D for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. y. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART D CERTIFICATION Name of Inspector Ralph Ojala Company Name Down Cape Consulting Company Address 939 Route 6A, Yarmouthport, MA 02675 Certification Statement I certify that I have personally inspected the sewage disposal system at this .address •and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maaritenance of on-site sewage disposal systems. Chec one : iI have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR15. 303 . The basis for this ` determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature Date V ",-Lv 'a s, 114 �, Original to system owner Copies to: Buyer (if applicable) Approving authority ! wy t c-o � `�,l �� '..rt e." t elf ,I TOV;N OF BARNSSTABLE f LOCATION "� ��`<�� K ` SEWAGE # `7c VILLAGE G�!✓� % //� ASSESSOR'S MAP &LOT Z/Z7 INSTALLER'S NAME&PHONE NO. ��O�llJ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) y NO.OF BEDROOMS q l BUILDER OR OWNER GJle-115 PERMIT DATE: /�_��' S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �'S� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Cl Feet Furnished by /T� P 'J, I iF a d ;r T LOCATION SlyAU�Z=SEWAGE* VILLAGE ASSESSOR'S ASSESSOR'S MAP &LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 ,j ,'i _ / / BUILDER OR OWNER �f��l G+� (�/f/fCA PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �`Z Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /yc7 Feet Edge of Wetland and Leaching Facility(If any wetlands exist qe�,,��114 within 300 feet of 1 aching facility) Ab Feet Furnished by L � pX Oyr�r DEPTH�GROUf7Dl ATEr� r� r�-t i- ?g r i"� `�- depth to groundwater �: 1 SEPTIC PROFILE ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) M.k TEST HOLE LOGS ACCESS COVER (WATERTIGHT) TO A MINIMUM .75' OF COVER OVER PRECAST ir WITHIN e OF FIN GRACE 2% SLOP EQUIRED OVER SYSTEM Lac 4,itlfl-.f F VENTILATION PIPE A f DOUBLE RUN PIPE LEVEL /"- AND HOOD WASHED PEASTONE L (DB— FOR FIRST 2' WITNESS: Ar ORIFICES TO BE 3/8r TO 5/Er PROPOSED 46 GALLON SEPTIC n' 1 a'6 DATE: A Doe, TANK (H"0) IFT,- ,�1,-1�_ :v OOQQ 0- �?000 00 EL =J-1 T 0 r 0 0 O._PY12�5�a';!Lpl AJ to A PERC. RATE L014G BY WIDE H: ,30 0 1 6- CRUSHED STONE OR 1_('0yn ) — (-% SLOPE) DEPTH OF FLOW _COMPACTION. (1'�.221 MECHANICAL\ CLASS SOILS P# (21) \\---31Er TO 1-1/2- DOUBLE WASHED STONE A V_� TEE SIZES: J-7. SLOPE) Y. SLOPE) INLET DEPTH SIDES AND BOTTOM OF LEACH INTERFACE TO BE SCARIFIED LOCATION MAP 1 OUTLET DEPTH yr 2 � " ASSESSORS MAP — PARCEL LEACHING FOUNDATION-- 4� SEPTIC TANK D' BOX FACILITY FLOOD ZONE 0. 44.%2 01 0 — 4 BUILDING ZONE:- 57 SETBACKS: FRONT - SIDE 79 2S'i 4 5`1 - 't cl "A*4P REAR - il 0 6w( C1 C-7 PLAN REFERENCE: L , C-L' -�j V rwli�; -11 AP '4 1;L WAI I f AT- EL' 'j3.LtS C-A rn� A S L A 14 MAP 212 PARCEL 6 SEPTIC DESIGN: (GARBAGE DISPOSER IS WOT - NOT E'S B DESIGN FLOW: BEDROOMS GPD) GPD 1 . DATUM IS IS",1� USE A44-CL GPD DESIGN FLOW j� #6 I - 1) - 111, 1 )'i 40 2. MUNICIPAL WATER SEPTIC TANK: GPD GALLONS / 0 5 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ,� g \ O.c� v� USE A GALLON SEPTIC TANK 41 P 1�� 4. SIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H__'�-7r) k'- C _ 4 -f� L'EA g_H I N Q, t�S _5 r1IPE JOINTS TO BE MADE WATERTIGHT. 't -"*) "I. ! . SIDES: GPD 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 4-2 #3 BOTTOM: GPO ENVIRONMENTAL CODE TITLE V. I Lt - -0-,4w TOTAL: S.F. A5_12�2_GPO THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING. Lr Avork t line R P!Pr7 C- rD C-9:PTIr' SYSTFkA, TO SCH. $IIt f nc r� 4, r� V .V'T I it LOT AREA__ A 1--r I R -V 0I VS 9. EXISTING CESSPOOLS TO BE PUMPED AND FILLED WITH CLEAN SAND. C)t") 0. ArAt_- 10. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT R.q_oo,,r 4',' tree line �A I,/z* 1y"P'r'w INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED Y,,,r FROM BOARD OF HEALTH. 11 err 177,968 SF utility so line pole 4.09 ACRES "gu 11 . IT IS THE RESPONSIBILITY OF THE OWNER OR THE OWNER'S wire AGENT TO CONTRACT WITH THE DESIGNER FOR INSPECTION AND CERTIFICATION OF CONSTRUCTION AND LOCATION OF SYSTEM 1 AS PER TITLE 5 REGULATIONS, IF 12. VEHICULAR TRAFFIC, PARKING OF VEHICLES, STOCKPILING OF MATERIALS d 0. AND STORAGE OF EQUIPMENT OVER LEACHING AREA PROHIBITED AT t4t)- + ALL TIMES. cl, case -4— 13. SYSTEM AREA SHALL BE STAKED AND FLAGGED FROM DATE OF covers INSTALLATION UNTIL CERTIFICATE OF COMPLIANCE IS ISSUED. AV RIV OVERHEAD 14. AREA DOES NOT LIE WITHIN NITROGEN SENSITIVE AREA. 11A/A WIRES 15. V C -P I PE t wj�_ T�EL_0k)� At, to PC i. C'L_ -I R, --PQ t Orz. C)I- ncrete rQ 01 Patio elev. 43.3' _j WELL chimney One stwy Wood dwelling -0 ti 1 _ , , ..................... .......... SITE AND SEWAGE PLAN OF 13 Z,44 A L tT' -W-'C , IN THE TOWN OF: CESSP OOL D+ COVERS BOARD OF HEALTH !z-A 1:Z-'t-1 F, r .... ... MAP 21 1 PARCEL 6 MA PREPARED FOR:APPROVED DATE 4 L �o T. 0 Feet SCALE: 1'�_ZO" DATE: A > K-._ 3 L :39 07 down cape engineering, inc. CIVIL ENGINEERS LAND SURVEYORS D P. DATE PHONE 508-382-4541 FAX 508--382-9880 Re U 939 main st. yarmouth, ma